Personal information on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of reviewing your claim.
Your online claim has been submitted to Legal Services.
Once a claim file has been opened, you can expect to receive a formal acknowledgement within two weeks of today's date.
In most cases, an investigation will be commenced and a final response will be forwarded to you within six weeks. However, this is not a guarantee as some require a longer response time.
* = Required
* First Name
* Last Name
* Postal Code
Enter at least one valid method of contact.
* Incident Date
* City / Town
Select a city...
Details and Description of Incident
(attach copies of invoices, estimates, receipts near bottom of page)
This claim involves vehicle damage due to roadway disrepair
Make / Model
(at the time of the incident)
16 or more
(In vehicle at the time of the incident)
Direction of Vehicle
Speed of Vehicle
Condition of Road
Describe the weather conditions at time of incident
Describe the exact location of the disrepair on the roadway
(Was the disrepair located on the paved portion or shoulder area?)
Describe the disrepair on the roadway (include dimensions)
Describe any signs that warn of road disrepair(e.g. construction signs, traffic cones, bump ahead)
List names of any independent witnesses
There was construction in the area
I have notified my auto insurance company
(assigned to your claim)
Submit electronic documents (photos, reports) supporting my claim. Each file has to be a maximum of 5 MB, and all files must be less than 10 MB.
Only PDF, JPG, DOC(X), XLS(X), PNG and TXT formats will be accepted.
I will send other documentation by mail.
Mail Documentation to:
Claim Submission, c/o Regional Clerk
Sir Isaac Brock Way, P.O. Box 1042
Thorold, ON L2V 4T7
Mail Documentation to:
Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.
Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.
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